Risk factors for self-reported insufficient milk during the first 6 months of life: A systematic review.

The objective of this systematic review was to identify multifactorial risk factors for self-reported insufficient milk (SRIM) and delayed onset of lactation (DOL). The review protocol was registered a priori in PROSPERO (ID# CDR42021240413). Of the 120 studies included (98 on SRIM, 18 on DOL, and 4 both), 37 (31%) studies were conducted in North America, followed by 26 (21.6%) in Europe, 25 (21%) in East Asia, and Pacific, 15 (12.5%) in Latin America and the Caribbean, 7 (6%) in the Middle East and North Africa, 5 (4%) in South Asia, 3 (2.5%) in Sub-Saharan Africa, and 2 (1.7%) included multiple countries. A total of 79 studies were from high-income countries, 30 from upper-middle-income, 10 from low-middle-income countries, and one study was conducted in a high-income and an upper-middle-income country. Findings indicated that DOL increased the risk of SRIM. Protective factors identified for DOL and SRIM were hospital practices, such as timely breastfeeding (BF) initiation, avoiding in-hospital commercial milk formula supplementation, and BF counselling/support. By contrast, maternal overweight/obesity, caesarean section, and poor maternal physical and mental health were risk factors for DOL and SRIM. SRIM was associated with primiparity, the mother's interpretation of the baby's fussiness or crying, and low maternal BF self-efficacy. Biomedical factors including epidural anaesthesia and prolonged stage II labour were associated with DOL. Thus, to protect against SRIM and DOL it is key to prevent unnecessary caesarean sections, implement the Baby-Friendly Ten Steps at maternity facilities, and provide BF counselling that includes baby behaviours.

Impact of prelacteal feeds and neonatal introduction of breast milk substitutes on breastfeeding outcomes: A systematic review and meta-analysis.

The introduction of fluids other than breast milk during the first few days of life or later neonatal period has been identified as a risk factor for suboptimal breastfeeding (BF) outcomes in numerous studies using varying study designs. However, the relationship between early introduction of fluids other than breast milk and BF outcomes has not been systematically assessed using only prospective studies that can establish temporality, which is critical for determining whether observed associations are causal. We conducted a systematic review and meta-analysis of prospective studies to assess if there is a difference in BF outcomes as a result of the introduction of: (a) milk-based prelacteals, (b) water-based prelacteals and (c) breast milk substitutes (BMS) between 4 days and 4 weeks postpartum. We searched PubMed, Lilacs, Web of Science and other repositories for original research investigating the relationship between early introduction of prelacteals and/or BMS and BF outcomes. Forty-eight studies met the inclusion criteria for the systematic review. Of the 39 prelacteal feeding studies, 27 had the prerequisite statistical information for inclusion in the meta-analysis. Findings from the meta-analysis showed a relationship between prelacteals and exclusive BF cessation (RR 1.44; 1.29-1.60) and any BF cessation (2.23; 1.63-3.06) among infants under 6 months old. Nine studies focusing on the introduction of BMS during the neonatal period identified this practice as a statistically significant risk factor for a shorter BF duration. Effective interventions are needed to prevent the introduction of unnecessary milk-based prelacteals and BMS during the perinatal and neonatal periods to improve BF outcomes.

Impact of breastfeeding interventions among United States minority women on breastfeeding outcomes: a systematic review.

BACKGROUND: In the U.S., strong ethnic/racial, socioeconomic, demographic, and geographic breastfeeding (BF) inequities persist, and African American and Hispanic women are less likely to meet their breastfeeding goals compared to White women. This systematic review (SR) was designed to answer the question: What is the impact of breastfeeding interventions targeting ethnic/racial minority women in the U.S. on improving BF initiation, duration and exclusivity rates? METHODS: The SR was conducted following the Institute of Medicine Guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The study protocol was developed and registered a priori in PROSPERO (ID#CRD42020177764). The electronical databases searched was MEDLINE All (Ovid). Search strategies were led by the team's expert public health librarian using both controlled vocabulary and free text queries and were tested against a validated set of relevant papers included in existing reviews. The GRADE methodology was used to assess the quality of the studies. RESULTS: We included 60 studies that had randomized (n = 25), observational (n = 24), quasi-experimental (n = 9), or cross-sectional (n = 2) designs. The studies focused on populations that were multi-ethnic/racial (n = 22), only Hispanic (n = 24), only Black (n = 13), and only American Indian (n = 1). The study interventions were classified following the socioecological model: macrosystem/policy level (n = 6); community level (n=51), which included healthcare organizations (n = 34), The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (n = 9), and community organizations/public health institutions (n = 8); and  interpersonal level (n = 3). CONCLUSIONS: Policy and community level interventions delivered through WIC, healthcare facilities, and community agencies) are likely to improve BF outcomes among women of color. The combination of interventions at different levels of the socioecological model has not been studied among minority women in the U.S. Implementation science research is needed to learn how best to scale up and sustain effective BF interventions, taking into account the needs and wants of minority women. Thus, it is strongly recommended  to conduct large scale implementation research studies addressesing how to strengthen the different health and social environments surrounding women of color in the U.S. to improving their BF outcomes.

A self-applied valid scale for rapid tracking of household food insecurity among pregnant women in Sri Lanka.

Rapid household food insecurity (HFI) tracking has been identified as a priority in the context of the COVID-19 pandemic and its aftermath. We report the validation of the Latin American and Caribbean Food Security Scale (Escala Latinoamericana y Caribena de Seguridad Alimentaria [ELCSA]) among pregnant women in Sri Lanka. The eight-item adult version of the ELCSA was translated from English to Sinhala and Tamil. Cognitive testing (on 10 pregnant women and five local experts) and psychometric validation of the self-administered HFI tool were conducted among pregnant women (n = 269) attending the special clinics of the Rajarata Pregnancy Cohort (RaPCo) in Anuradhapura in February 2020. We assessed the psychometric properties and fit using a one parameter logistic model (Rasch model analysis) using STATA Version 14 and WINSTEP software Version 4.3.4. Concurrent validity was tested using psychological distress. The scale was internally consistent (Cronbach's alpha = 0.79) and had a good model fit (Rasch items infit statistic range: 0.85 to 1.07). Item 8 ('did not eat for the whole day') was removed from the model fit analysis, as it was not affirmed by respondent. Item severity scores ranged from -2.15 for 'not eating a diverse diet' to 4.43 for 'not eating during the whole day'. Concurrent validity between HFI and psychological distress was confirmed (r = 0.15, p < 0.05). The self-applied version of ELCSA-pregnancy in Sri Lanka (ELCSA-P-SL) is a valid and feasible valid tool. We recommend it to track HFI among pregnant women in lower income countries during the COVID-19 pandemic.

Content analysis of media coverage of breastfeeding in Mexico.

Media can be a powerful communication tool to promote breastfeeding programs, influence mother's breastfeeding behaviour, and generate support among stakeholders for breastfeeding. Yet, there is little information on how media coverage influences a country's breastfeeding enabling environment. This study addressed this gap by conducting a retrospective content analysis of documents published between January 1, 2017 and January 1, 2018 to analyse the media coverage related to breastfeeding in Mexico. Content analysis was based on the breastfeeding gear model and a strategic planning technique to identify strengths, weaknesses, opportunities, and threats for enabling the national breastfeeding environment. Media coverage of breastfeeding was more frequent in August (36% of all documents). The top three topics commonly covered by the media were advocacy events promoting breastfeeding, promotion campaigns, and changes in breastfeeding legislation and policy. In general, the media coverage focused on strengths of specific breastfeeding policies. There was limited news coverage of key factors that negatively influenced or threatened the breastfeeding environment. Findings support the need to design strategies to engage the media covering in more depth and breadth diverse aspects of breastfeeding protection, promotion, and support efforts in Mexico.

How does "Becoming Breastfeeding Friendly" work? A Programme Impact Pathways Analysis.

Becoming Breastfeeding Friendly (BBF) is an initiative designed to track country readiness and progress to effectively scale up breastfeeding programmes. BBF includes a policy toolbox that has three components: the BBF Index (BBFI), case studies, and a five-meeting process. Mapping pathways of how BBF was implemented and utilized enables contextually grounded interpretation of its impact on breastfeeding outcomes. We conducted a programme impact pathways (PIP) analysis to identify pathways and critical quality control points (CCPs) by which BBF can enable changes in policy, legislation, and implementation of breastfeeding programmes. A BBF PIP diagram was developed, and CCPs were identified through a literature review and an iterative interviewing process with BBF investigators. The PIP was revised after feedback from BBF's Technical Advisory Group. BBF pretesting in Ghana and Mexico informed the formative evaluation of the PIP. PIP analysis identified relevant pathways between BBF activities and outcomes. Eight CCPs that could facilitate or attenuate BBF to fully impact the scaling up of the breastfeeding programmes were identified: (a) committee formed and trained; (b) committee understands BBF and BBFI; (c) committee's ability to acquire data; (d) BBFI scores; (e) criteria used for prioritizing recommendations; (f) dissemination of recommendations; (g) policymaker's reactions and media coverage; (h) committee's motivation and effective teamwork throughout BBF. Ghana and Mexico's pretesting of BBF confirmed the CCPs and provided valuable insights on potential mechanisms of BBF impacts at the country level. To further validate the PIP, a policy analysis framework is being tested in Ghana and Mexico.

Factors influencing the implementation of the Becoming Breastfeeding Friendly initiative in Ghana.

Becoming Breastfeeding Friendly (BBF) is an initiative designed to help countries assess their readiness to scale-up breastfeeding programs and develop key recommendations to strengthen their breastfeeding environment. In 2016, Ghana was one of two countries to first pilot BBF. In applying BBF, a committee of 15 Ghanaian nutrition, health, and breastfeeding experts implemented the BBF toolbox over 8 months. Following implementation, semistructured interviews were conducted with 12 committee members (CMs) to (a) identify facilitators and barriers to implement BBF and (b) determine factors needed to strengthen the breastfeeding environment in Ghana. Using a grounded theory approach, five domains were identified. First, a dynamic committee of key stakeholders drove the implementation of BBF. Second, CMs faced some logistical and methodological challenges, including difficulty accessing data and the need for strong in-country technical support for adhering to the BBF process. Third, CMs felt well positioned to facilitate and lead the dissemination and implementation of recommendations. Fourth, accountability would be essential to properly translate recommendations. Fifth, to move recommendations to action, advocacy would be a required first step, and BBF was proposed to facilitate this step. BBF provided an in-depth analysis of Ghana's current breastfeeding environment to help Ghana strengthen its breastfeeding governance, policies, and programs while informing CMs' government and non-governmental organizations' breastfeeding efforts.

Development and pretesting of "Becoming Breastfeeding Friendly": Empowering governments for global scaling up of breastfeeding programmes.

Scaling up breastfeeding programmes has not been highly prioritized despite overwhelming evidence that breastfeeding benefits the health of mothers and children. Lack of evidence-based tools for scaling up may deter countries from prioritizing breastfeeding. To fill this gap, Becoming Breastfeeding Friendly (BBF) was developed to guide countries in effectively scaling up programmes to protect, promote, and support breastfeeding. BBF includes an evidence-based toolbox that consists of a BBF Index, case studies, and a 5-meeting process. These three interrelated components enable countries to assess their breastfeeding scaling up environment, identify gaps, propose policy recommendations, develop a scaling up plan, and track progress. The toolbox was developed based on current evidence and expert guidance from a Technical Advisory Group, which was composed of global breastfeeding and metric experts with experience in the scaling up of health and nutrition programmes in low-, middle-, and high-income countries. The BBF toolbox required a step-by-step iterative approach to describe and systematize each component, thus an operational manual was developed. The BBF toolbox and BBF operational manual underwent intensive pretesting in two countries, Ghana and Mexico, resulting in the modification of each component plus the operational manual. Pretesting continues in six additional countries demonstrating that BBF is a robust and dynamic multi-sectoral process that, with relatively minor adaptations, can be successfully implemented in countries across world regions.

Becoming Breastfeeding Friendly Index: Development and application for scaling-up breastfeeding programmes globally.

Global efforts to further improve exclusive breastfeeding rates have not been successful, in part because effective scaling-up frameworks and roadmaps have not been developed. The Becoming Breastfeeding Friendly (BBF) toolbox includes an evidence-based index, the BBF Index (BBFI), to guide the development and tracking of large scale, well-coordinated, multisector national breastfeeding promotion programmes. This paper describes the development of the BBFI, which is grounded in the Breastfeeding Gear Model complex adaptive systems framework. The BBFI was developed by the BBF Steering Committee in collaboration with a high-level Technical Advisory Group following the Delphi consensus methodology. Key benchmarks and definitions were informed by evidence-based health, nutrition, and newborn survival initiatives identified from the academic and grey literature. The BBFI consists of 8 gears (54 benchmarks): Advocacy (4); Political Will (3); Legislation and Policies (10); Funding and Resources (4); Training and Program Delivery (17); Promotion (3); Research and Evaluation (10); and Coordination, Goals, and Monitoring (3). Scores are generated for 8 gear scores plus a total country score to gauge the scaling-up enabling environment. The BBFI provides an evidence-based index to assist countries in (a) assessing their readiness to scale up breastfeeding programmes and (b) tracking scaling-up progress.

Length of time in Ghana is associated with the likelihood of exclusive breastfeeding among Liberian refugees living in Buduburam.

While literature describing immigrant's breastfeeding practices exists, especially among those living within developed countries, there is a significant gap in knowledge on how the host culture may influence the EBF behaviors of refugees, especially those living in protracted situations within sub-Saharan Africa. A cross-sectional study was conducted in the Buduburam Refugee Settlement in Ghana from July-August 2008 to explore the association between the amount of time living in Ghana and exclusive breastfeeding practices among Liberian refugees and Ghanaians in surround villages. The study included 480 women: 239 Liberians living in 12 settlement zones (in two of which Liberians and Ghanaians co-exist), 121 Ghanaians living in two settlement zones, and 120 Ghanaians living in nearby urban village of Awutu. Liberian mothers who lived in Ghana at least eight years were significantly more likely to exclusively breastfeed (OR: 1.78, 95% CI: 1.02, 3.09) compared to Ghanaian mothers living in Awutu. These findings suggest that increased time living in Buduburam improved the chances of EBF success among Liberians, perhaps as a result of unique EBF education/support opportunities offered in the settlement to Liberian refugees that were not readily available to Ghanaians. Further research to understand the "mechanisms" explaining exclusive breastfeeding differences as a function of time spent in host country is needed for improving breastfeeding support in refugee settlements and host communities.

Dietary patterns in Liberian refugees in Buduburam, Ghana.

Previous research suggests that acculturation (i.e., exposure and assimilation to local culture) is associated with changes in dietary patterns among immigrants. This study investigates this association in a refugee population using time in refugee settlement as a proxy for acculturation. A cross-sectional survey was conducted among a systematic sample to (a) identify dietary patterns in Liberian refugees and Ghanaians living in or near a refugee settlement, (b) compare adherence to these dietary patterns between groups, and (c) investigate the association between acculturation and dietary patterns in Liberian refugees. Participants were Liberian and Ghanaian women with young children living in the Buduburam refugee settlement or Awutu in Ghana (n = 480; 50% Liberian; mean age 28, SD 6.3, range 16-48 years). Time in settlement was assessed by self-report; food consumption was assessed by food frequency questionnaire. Principal component analysis was used to identify dietary patterns; a generalized linear model was used to test the association of interest. Three distinct dietary patterns emerged: Healthy, Sweets, and Fats. Ghanaians were more adherent to the Healthy pattern than Liberians (p < 0.05). Liberians were more adherent to the Sweets and Fats patterns than Ghanaians (p < 0.05). There were no significant differences in dietary pattern adherence among the Liberians based on time in settlement. Ghanaians living in Awutu were more adherent to the Healthy pattern than Ghanaians who lived in settlement (p < 0.05). Differences in dietary patterns were observed between Liberian refugees and Ghanaians. These differences were not associated with acculturation and may be related to the food environment in the settlement.

Acculturation and Diabetes Risk in the Mexican American Mano a Mano Cohort.

OBJECTIVES: To investigate the association between acculturation and diabetes risk in the Mexican American Mano a Mano (hand to hand) Cohort. METHODS: We recruited 15 975 men and women in the Houston, Texas, area from 2001 to 2014. We used language use, birth country, and duration of US residence (among Mexico-born) to assess acculturation. Participants self-reported a physician's diagnosis of diabetes during annual follow-up over an average of 5.4 (range = 1-13) years. Self-reported diabetes status was validated in medical records for a subset of 235 participants with 98% agreement. RESULTS: Diabetes risk was higher among immigrants with 15 to 19, 20 to 24, and 25 or more years (relative risk = 1.47; 95% confidence interval = 1.07, 2.01) of US residence, relative to those with less than 5 years. Neither language acculturation nor birth country was significantly associated with diabetes risk. CONCLUSIONS: Among participants born in Mexico, diabetes risk increased with longer duration of US residence.

Clients' experiences and satisfaction with produce prescription programs in California: a qualitative evaluation to inform person-centered and respectful program models.

Background: Produce prescription programs have strong potential to improve food security, fruit and vegetable consumption, and health across the life course. Understanding clients' experiences and satisfaction with produce prescription programs is critical for evaluating the person-centeredness and quality of these programs. The objectives of this study were to (1) describe client experiences and satisfaction with produce prescription programs, with an emphasis on the extent to which they felt they were treated with respect and dignity, and (2) identify recommendations for improving client experiences. Methods: We conducted four focus group discussions with clients of produce prescription programs in two Federally Qualified Health Centers in California. We used a modified framework analysis approach and organized participants' experiences with programs into themes. Results: Three themes captured participants' program experiences. First, respectful produce prescription programming encompassed interactions with individuals delivering the programs that felt respectful (e.g., program staff showing they cared about participants' health and offering timely assistance with financial incentives) and disrespectful (e.g., not receiving prompt responses to questions about incentives), as well as aspects of program design perceived to be respectful (e.g., provision of gift cards as financial incentives, which offered privacy when purchasing produce). Second, having autonomy to use gift cards to choose their preferred fresh fruits and vegetables was viewed as a positive experience, though participants desired greater autonomy to shop at stores other than the program designated stores. Third, participants frequently discussed program usability, with some reporting that joining the programs and using the cards was easy, and others describing difficulties activating cards and using them at stores due to cashiers' lack of awareness of the programs. Overall, participants were highly satisfied with the programs. To improve client experiences, they recommended increasing privacy (e.g., by educating cashiers on the programs so that clients do not need to explain in public what the card is for) and autonomy (e.g., allowing cards to be used at other chain or local stores). Discussion: Our findings inform efforts to make produce prescription programs more person-centered and respectful, which in turn may increase program demand, engagement, and impact.

Persistent household food insecurity, HIV, and maternal stress in peri-urban Ghana.

BACKGROUND: The mental health of caregivers has been shown to be important for improving HIV prevention and treatment. Household food insecurity affects hundreds of millions of individuals in Sub-Saharan Africa, a region that experiences a disproportionate burden of the HIV pandemic. Both maternal HIV diagnosis and household food insecurity may be linked with maternal stress. This in turn may lead to unhealthy coping behaviors. We examined the independent associations of HIV, persistent household food insecurity and the synergistic effect of both on maternal stress. METHODS: Ghanaian women recruited prenatally from hospitals offering voluntary counseling and testing (VCT) were followed for 12 months after childbirth (N = 232). A locally adapted 7-item version of the US Household Food Security Survey Module was applied at four time points postpartum. We dichotomized participant households as being persistently food insecure (i.e., food insecure at each time point) or not (i.e., food secure at any time point). We dichotomized participant women as not perceiving vs. perceiving stress at 12 months postpartum in reference to the median sample score on the 4-item Cohen's stress scale. Binary multivariate logistic regression models were used to assess the independent and interactive effects of maternal HIV and persistent household food insecurity on maternal stress. RESULTS: The proportion of HIV-positive women that lived in severe food insecure households increased over time. By contrast, the HIV-negative group living in severely food insecure households experienced a steady decline across time. HIV-infection (AOR = 2.31, 95% CI 1.29-4.12) and persistent household food insecurity (AOR = 3.55, 95% CI 1.13-11.13) were independently associated with maternal stress in a multivariate model. Being both HIV-positive and persistently food insecure strongly and synergistically increased the risk for maternal perceived stress (AOR = 15.35, 95% CI 1.90-124.14). CONCLUSION: In agreement with syndemic theory there is a powerful synergism between maternal HIV diagnosis and household food insecurity on maternal stress. Comprehensive multi-dimensional intervention studies are needed to better understand how to reduce stress among HIV-positive women living in persistently food insecure households and how to reduce the likelihood of food insecurity in HIV-affected households in Sub-Saharan Africa.

Consensus-building during the Becoming Breastfeeding Friendly (BBF) initiative in Samoa: A qualitative content analysis.

The Becoming Breastfeeding Friendly (BBF) initiative provides countries with an evidence-based toolbox to improve the national breastfeeding environment by assessing and developing a plan to effectively scale up well-coordinated national policies and programs. BBF is carried out by a multi-institutional, intersectoral committee of experts, convening across five committee meetings designed to produce policy recommendations that can be implemented in the country's context. Samoa successfully completed the BBF initiative in 2018, resulting in the institution of breastfeeding policy in hospitals and the establishment of lactation rooms within government ministries. An important step in informing the success of future breastfeeding scale-up initiatives is understanding how consensus is built. This study aimed to investigate how the BBF Samoa committee built consensus. We conducted a content analysis of audio recordings of three BBF Samoa meetings (meetings 1, 2 and 4), meeting minutes, and meeting notes using an a priori operational consensus-building framework. We used a combination of deductive and inductive approaches to: a) evaluate the data against existing, a priori criteria for consensus-building and b) identify emergent ways in which the BBF Samoa committee may have achieved consensus. We identified 6 themes, 2 meta-subthemes, and 16 subthemes. The 6 themes, largely defined by the a priori framework, represented key components of successful consensus-building. The 2 meta-subthemes described two overarching methods of consensus-building: "process-led" (i.e., inherent to the BBF process itself) and "organic" (unique/specific to the committee). Lastly, the 16 subthemes described more specific ways that the committee reached consensus. The detailed manualization of the BBF process, its reliance on data, and its transparent and engaged committee process were key for reaching consensus on BBF scores and recommendations in Samoa. Our study contributes to the understanding of how effective breastfeeding policy recommendations are made, using a methodology that can be applied beyond the topic of breastfeeding.

Risk factors for household food insecurity in the Eastern Caribbean Health Outcomes Research Network cohort study.

Background: Globally, 1.3 billion people were considered food insecure as of 2022. In the Caribbean region, the prevalence of moderate or severe food insecurity was 71.3% as of 2020, the highest of all subregions in Latin America. Experienced based measurement scales, like the Latin American and Caribbean Food Security Scale, are efficient measurement tools of food insecurity used globally. The Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study is a population-based longitudinal cohort study in the two Caribbean U.S. territories of Puerto Rico and the U.S. Virgin Islands, as well as in Barbados and Trinidad & Tobago. The purpose of this research was to examine the demographic, psychosocial, behavioral, and environmental risk factors associated with household food insecurity (HFI) among adults ≥40 years of age in the ECHORN cohort. Methods: A cross-sectional analysis of baseline ECHORN cohort study data was conducted. The primary outcome was household food insecurity (none, mild, moderate/severe). A total of 16 known and potential risk factors were examined for their association with HFI. The ANOVA and chi-square statistics were used in bivariate analysis. Ordinal logistic regression was used for the multivariable and sex stratified analyses. Results: More than one-quarter of the sample (27.3%) experienced HFI. In bivariate analyses, all risk factors examined except for sex, were significantly associated with HFI status. In the multivariable analysis, all variables except sex, education, marital status, smoking status, and residing in Puerto Rico were significant predictors of HFI in the adjusted model. In sex stratified analysis, depression, food availability, self-rated physical health, and island site were significantly associated with increased odds of worsening HFI for women, but not for men. Source of potable water was an important risk factor for both men and women. Discussion: The prevalence of HFI in the ECHORN cohort study is comparable to other studies conducted in the region. While women did not have an increased risk of HFI compared to men, a different set of risk factors affected their vulnerability to HFI. More research is needed to understand how water and food security are interrelated in the ECHORN cohort.

Nutrient and food intakes differ among Latina subgroups during pregnancy.

OBJECTIVE: To document nutrient and food group serving intakes from food sources among Latina subgroups living in the same geographical area. DESIGN: A cross-sectional study. Nutrient and food group serving intakes were assessed by means of a 24 h recall administered immediately after a prenatal survey. SETTING: Hartford, CT, USA. SUBJECTS: A total of 233 low-income pregnant Latinas. For analyses, Latinas were classified into two groups on the basis of self-reported ethnic identity: Puerto Ricans and non-Puerto Rican Latinas. RESULTS: Puerto Rican Latinas were more likely than non-Puerto Rican Latinas to be more acculturated and to consume foods (i.e. processed meat, cheese, soft drinks) and higher levels of nutrients (i.e. fat, SFA, MUFA, trans fatty acids) that have been implicated in the development of chronic diseases. By contrast, non-Puerto Rican Latinas were more likely to consume foods (i.e. fruits, dark green/yellow vegetables, tomatoes, non-starchy vegetables) and higher levels of nutrients (i.e. fibre, vegetable protein, folate, ß-carotene) that promote health when compared with Puerto Rican Latinas. CONCLUSIONS: Findings suggest that acculturation may play a role in dietary intake. Clinicians and dietitians need to be aware of these differences to encourage healthy eating patterns among more acculturated pregnant Latina clients.

Strengthening Maternal, Infant, and Young Child Nutrition Training and Counseling in Ghana: A Community-Based Approach.

Background: Evidence-based maternal, infant, and young child nutrition (MIYCN) counseling provides caregivers essential nutrition education to optimize infant and young child feeding practices and subsequently improve child growth and development. Effective integration of responsive feeding (RF) into current MIYCN training requires working with priority communities. Objectives: Study objectives were to 1) assess MIYCN knowledge and practices among Ghanaian caregivers, 2) identify factors influencing RF/responsive parenting (RP) among Ghanaian caregivers, 3) identify barriers and facilitators influencing MIYCN training and counseling among Ghanaian health care providers, and 4) document recommendations for integrating an RF curriculum into the existing MIYCN training. Methods: This was a qualitative study, conducted within the Central Region of Ghana, based on 1) 6 focus groups with caregivers of young children (<36 mo; n = 44) and 2) in-depth interviews with health care providers (n = 14). Focus group transcripts were coded independently, consensus was reached, and a final codebook developed. The same coding process and thematic analysis were applied to the in-depth interviews. Results: Caregivers identified 3 domains influencing the primary outcome of RF/RP knowledge and practices and the secondary outcome of MIYCN: 1) health care provider counseling; 2) support from family, friends, and community members; and 3) food safety knowledge and practice. Providers identified barriers to MIYCN provider training as well as caregiver counseling which included limited access to financial and counseling resources and limited qualified staff to deliver infant and young child feeding counseling. Identified facilitators included availability of funding and counseling staff with adequate resources. Health care providers strongly endorsed integrating an RF curriculum into MIYCN training and counseling along with providing RF training and distribution of RF materials/tools to facilities. Conclusions: Health care providers directly influenced RF/RP practices through MIYCN counseling. Strengthening MIYCN counseling through the integration of an RF curriculum into MIYCN training is desired by the community.

Assessing the Nurturing Care Content of UNICEF's Community Infant and Young Child Feeding Counselling Package: Gaps, Best Practices, and Lessons Learned.

Background: The United Nations Children's Fund (UNICEF) Community Infant and Young Child Feeding Counselling Package (C-IYCF CP) is used globally for infant and young child feeding (IYCF) counseling. With the C-IYCF CP last updated 8 y ago, mapping existing nurturing care content, identifying gaps, and documenting current country-level changes offers a unique opportunity to guide recommendations to strengthen the nurturing care content of this package. Objectives: The primary study aims were to: 1) identify and map existing nurturing care content within UNICEF's C-IYCF CP, 2) identify gaps related to nurturing care or feeding elements within the C-IYCF CP, 3) identify country-level nurturing care adaptations to the C-IYCF CP, and 4) identify best practices and lessons learned from country adaptations that can be recommended for inclusion in the C-IYCF CP. Methods: The assessment included 4 phases: 1) conduct an iterative process to identify and map nurturing care elements within the C-IYCF CP using a codebook explicitly developed for this assessment; 2) identify gaps in the C-IYCF CP; 3) apply the codebook to IYCF packages from 11 countries, revise, then finalize the codebook; and 4) identify and interview key informants from 4 countries whose IYCF packages had the most comprehensive nurturing care content plus 1 country where health care professionals make routine mother-child home visits. Results: The C-IYCF CP contained limited nurturing care content, especially around safety/security and early learning. All 5 countries interviewed had systematically identified and included priority nurturing care content in each package, yet content level varied. Two countries were also incorporating information technology into the training and delivery of the C-IYCF CP. Conclusions: Existing country-level best practices can address nurturing care elements missing from UNICEF's C-IYCF CP. Sharing these practices can allow countries to make context-driven, evidence-informed decisions on the nurturing care content to prioritize.

How much does it cost to implement the Baby-Friendly Hospital Initiative training step in the United States and Mexico?

The Baby-Friendly Hospital Initiative (BFHI) has been shown to increase breastfeeding rates, improving maternal and child health and driving down healthcare costs via the benefits of breastfeeding. Despite its clear public health and economic benefits, one key challenge of implementing the BFHI is procuring funding to sustain the program. To address this need and help healthcare stakeholders advocate for funds, we developed a structured method to estimate the first-year cost of implementing BFHI staff training, using the United States (US) and Mexico as case studies. The method used a hospital system-wide costing approach, rather than costing an individual hospital, to estimate the average per birth BFHI staff training costs in US and Mexican hospitals with greater than 500 annual births. It was designed to utilize publicly available data. Therefore, we used the 2014 American Hospital Association dataset (n = 1401 hospitals) and the 2018 Mexican Social Security Institute dataset (n = 154 hospitals). Based on our review of the literature, we identified three key training costs and modelled scenarios via an econometric approach to assess the sensitivity of the estimates based on hospital size, level of obstetric care, and training duration and intensity. Our results indicated that BFHI staff training costs ranged from USD 7.27-125.39 per birth in the US and from PPP 2.68-6.14 per birth in Mexico, depending on hospital size and technological capacity. Estimates differed between countries because the US had more hospital staff per birth and higher staff salaries than Mexico. Future studies should examine whether similar, publicly available data exists in other countries to test if our method can be replicated or adapted for use in additional settings. Healthcare stakeholders can better advocate for the funding to implement the entire BFHI program if they are able to generate informed cost estimates for training as we did here.